Circumferential dissection of the ascending aorta with intimal intussusception. Case report and review of the literature

The present report describes an unusual case (apparently the 10th in the world literature) of a type-A aortic dissection with full circumferential detachment of the ascending aortic intima and intussusception thereof into the aortic arch and descending aorta, partly occluding the arch vessels. Computed tomographic scanning and 2-dimensional echocardiography failed to detect an intimal flap and a false lumen in the ascending aorta. Aortic dissection was visualized by aortography. The ascending aorta was surgically repaired and the aortic valve resuspended. The pertinent literature is reviewed.

[Anatomo-functional correlations of changes in electrocardiographic repolarization in aortic and mitral valve insufficiency. Comparison of indices based on QRS voltages]

Electrocardiographic repolarization changes and voltage criteria for left ventricular hypertrophy were examined, in relation to hemodynamic, echocardiographic and angiographic data. This was done to evaluate their association with abnormalities in cardiac function and structure in 53 patients with chronic aortic regurgitation and 36 patients with chronic mitral regurgitation. No patient showed evidence of coronary artery disease. Of the patients with aortic regurgitation, the 27 patients with an abnormal repolarization pattern at ECG had worse NYHA functional class when compared to the 24 patients with normal repolarization (2.4 +/- 1 vs 1.6 +/- 0.9; p less than .01). They also had greater left ventricular dimensions (end-diastolic volume: 162 +/- 57 ml/m2 vs 109 +/- 15 ml/m2, p less than .01; end-systolic volume: 85 +/- 46 ml/m2 vs 44 +/- 31 ml/m2, p less than .01), lower left ventricular ejection fraction (.50 +/- .12 vs .63 +/- .14; p less than .01), greater left ventricular mass (170 +/- 56 gr/m2 vs 119 +/- 29 gr/m2; p less than .01) and higher end-diastolic left ventricular pressure (21 +/- 11 mmHg vs 11 +/- 8 mmHg; p less than .01). QRS voltage was less closely related to cardiac function and structure and thus, did not modify the conclusions based on repolarization findings alone. Furthermore, repolarization patterns identified patient subgroups with high or low prevalences of previously described predictors of poor surgical outcome. The presence or absence of the "strain" pattern was not related to differences in cardiac structure and function, in patients with mitral regurgitation.(ABSTRACT TRUNCATED AT 250 WORDS)

[Surgical results in mitral insufficiency: prognostic value of the indices of left ventricular function]

Left ventricular function is a major prognostic factor in patients with mitral regurgitation, but the ability of echocardiographic and hemodynamic parameters to predict the surgical result is controversial. We investigated the prognostic role of various pre-operative indices of left ventricular function in 23 consecutive patients who underwent successful surgical correction of chronic mitral regurgitation. At a mean follow-up of 20 +/- 16 months, patients underwent echocardiography and radio-nuclide angiography and were grouped according to the post-operative left ventricular ejection fraction. Group A was made up of 16 patients with a left ventricular ejection fraction greater than or equal to .45: they showed post-operative reduction of the left ventricular end-diastolic diameter (from 36.3 +/- 3.2 to 30.5 +/- 4.5 mm/m2; p less than .001) and of the radius/thickness ratio (from 3.5 +/- 0.6 to 2.9 +/- 0.6; p less than .01). In 7 patients (group B), post-operative left ventricular ejection fraction was less than .45 and no significant changes in the left ventricular end-diastolic diameter (from 41.5 +/- 2.7 to 36.9 +/- 6.1 mm/m2; NS) or the radius/thickness ratio (from 3.9 +/- 0.9 to 3.4 +/- 1.0; NS) were observed. During the follow-up all group A patients remained asymptomatic or minimally symptomatic, whereas 2 group B patients died of refractory left ventricular failure. Pre-operative left ventricular volumes and diameters, both at end-diastole and end-systole, were significantly greater in group B patients.(ABSTRACT TRUNCATED AT 250 WORDS)

[Evaluation of the seriousness of aortic valve stenosis: calculation of the valvular area or peak? Reliability of Hakki's formula]

The severity of aortic valve stenosis should be assessed by means of the calculation of the valvular area; on the other hand, the routine use of the Gorlin's formula for the aortic area is laborious and time consuming. Recently Hakki proposed a simplified formula (area = cardiac output/square root gradient) for the calculation of valvular areas. This method does not require the assessment of the systolic ejection time or the transvalvular flow; furthermore, the peak systolic gradient instead of the mean gradient may be entered into the formula. We have evaluated the reliability of this formula on 83 patients with aortic valve stenosis either pure or with absent to mild aortic incompetence (angiographically first degree maximum). Twenty-eight patients had isolated aortic stenosis, 55 had associated mitral stenosis and/or mitral or tricuspid regurgitation. Our results show a good correlation between the values of valvular areas obtained by Hakki's formula and those obtained by Gorlin's formula (r = 0.90 in the first group and r = 0.91 in the second group of patients). On the contrary we observed a poor relationship between the peak systolic gradient and the valvular area, with a considerable scatter of the data, especially for low values of peak systolic gradient. We therefore conclude that the assessment of the aortic valve stenosis must be based on the estimation of the valvular area; in our hands the Hakki's formula has proven to be easy and sufficiently reliable for routine diagnostic studies.

[Usefulness of the combination of the dynamic electrocardiogram with esophageal pH measurement in the differential diagnosis of chest pain]

Several diseases of the gastrointestinal tract can cause angina-like chest pain. Differential diagnosis can be extremely difficult, especially when pathological gastroesophageal reflux is present. We present 10 cases, 2 males and 8 females, in which invasive and non invasive cardiological techniques were unable to indicate a clear diagnosis. We have therefore used a new technique which combines dynamic electrocardiography with 24 hours monitoring of esophageal pH, to correlate pain symptom with electrocardiographic changes and/or gastroesophageal reflux. Using this approach we have diagnosed the presence of isolated pathological gastroesophageal reflux in 3 patients, isolated ischemic heart disease in 2 cases, both conditions in 3 patients and no signs of either condition in the remaining 2 cases. We think that this technique is of special value in subjects suffering from both conditions (ischemic heart disease and gastroesophageal reflux). It provides objective documentation of the role of each disease in the genesis of pain which is essential in developing appropriate therapy.

[Corrected transposition of the great vessels in the adult. Presentation of a case simulating ischemic cardiopathy]

We report the clinical and laboratory findings in a 58 years old woman with corrected transposition of the great arteries (CTGA), who that presented typical angina pectoris. The diagnosis of ischemic heart disease was supported by the history of a previous myocardial infarction. Other findings were a systolic murmur of mild mitral regurgitation, left bundle branch block and enlarged left ventricle on the chest X-ray. Cardiac catheterization showed a corrected transposition of the great arteries (L-malposition with situs solitus); left and right coronary arteries were free of luminal stenosis. We suggest therefore that anginal chest pain may be due to myocardial ischemia induced by discrepancy between myocardial oxygen consumption and coronary blood flow. This complication may occur in patients with corrected transposition of great arteries surviving in adulthood.